Care One at Redstone

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents, (Resident #1) who required laboratory work for a urine culture and sensitivity test (test used to identify bacterial infection and determine the most effective antibiotic), the Facility failed to ensure nursing promptly notified the Physician, Physician Assistant, or Nurse Practitioner of the abnormal laboratory result, when Resident #1's laboratory results were sent to the facility on [DATE], but the provider was not made aware until 01/28/26, five days later resulting in a delay in treatment.

Inspectors wroteBased on records reviewed, interviews, and observations for one of three sampled residents, (Resident #1) who had a known food allergy to onions, the Facility failed to ensure his/her diet was free from allergens, when on 09/15/25, Resident #1 was served a meal that contained onions, Resident #1 consumed some of the meal, developed signs and symptoms of an allergic reaction, and was transferred to the Hospital Emergency Department (ED) for evaluation of anaphylaxis (a severe, potentially life-threatening allergic reaction) where he/she was admitted for further treatment.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to ensure one Resident (#157), out of total sample of 33 residents, was free from the use of physical restraints. Specifically, the facility failed to ensure Resident #157's Velcro self-releasing seatbelt was released during supervised activities and failed to evaluate Resident #157's ability to self-release the Velcro seatbelt every shift, restricting his/her ability to move freely when the Resident had a history of attempting to stand up from a seated position.

Inspectors wroteBased on interview and record review, the facility failed to provide nursing services consistent with professional standards of practice for two Residents (#175 and #4) out of a total sample of 33 residents. Specifically, for Resident #175 and Resident #4, the facility failed to reorder the Residents' medications resulting in the facility staff borrowing other Residents' medications to administer the prescribed dosages.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that one Resident (#14) received proper treatment and care to maintain mobility and good foot health, out of a total sample of 33 residents. Specifically, the facility failed to ensure Resident #14 received timely foot care and treatment in order to prevent potential and actual complications when Resident #14 was identified as being high risk due to a diagnosis of Diabetes, having elongated toenails that were affecting his/her balance and mobility, experiencing discomfort during physical therapy treatments, and received toenail care on 8/15/25, 73 days after the initial identification of need on 6/3/25.

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide appropriate treatment and services related to an indwelling urinary catheter (a thin, flexible tube inserted into the bladder to drain urine outside the body) for three Residents (#1, #2 and #3), out of a total sample of 33 residents. Specifically, the facility failed: 1. For Residents #1 and #3, to ensure staff followed the Physician's orders relative to the Foley (type of indwelling urinary catheter) catheter size, increasing the Resident's risk for indwelling urinary catheter complications; and 2. For Resident #2, to ensure the Resident's Foley catheter was secured with a securement device to reduce friction and movement at the insertion site.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that one Resident (#95), out of a total sample of 33 residents, had the ability to make choices about their daily preferences. Specifically, for Resident #95, the facility failed to ensure the Resident's preference to receive a peanut butter and jelly sandwich for dinner was honored.

Inspectors wroteBased on observations, interviews, and records reviewed, the facility failed to maintain infection control practices to provide a safe, sanitary, and comfortable environment and to prevent the potential spread of infection on two Units ([NAME] and [NAME]), out of five Units observed. Specifically, on the [NAME] Unit, the facility failed to ensure:1. Staff wore appropriate personal protective equipment (PPE) when providing incontinence care to a resident who was on contact precautions; [NAME] the [NAME] Unit, the facility failed to ensure:2. Contaminated gloves were disposed of properly and appropriate hand hygiene was performed after removal of contaminated gloves, increasing the potential spread of healthcare-associated infections.

Inspectors wroteBased on observations, interview, and record review, the facility failed to maintain a homelike environment for one Resident (#15), out of a total sample of 33 residents. Specifically, the facility failed to ensure timely repair of a cracked second floor bedroom window for Resident #15 when it had been reported to the facility 84 days prior.

Inspectors wroteBased on records reviewed and interviews for one of three sampled residents (Resident #1) who had a diagnosis of Epilepsy (seizures) and had a Physician's Orders for anti-convulsant medications (used to treat seizures), the Facility failed to ensure nursing notified the Provider when he/she did not receive the anti-convulsant medication as ordered.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled Residents (Resident #1) who had a diagnosis of Epilepsy (seizures) and had a Physician's Orders for anti-convulsant (used to treat seizures) medications, the Facility failed to ensure they obtained, and Resident #1 was provided the medication as ordered by his/her Provider.

Inspectors wroteBased on record review and interviews, for one of three sampled residents (Resident #1) who had a diagnosis of Epilepsy (seizures) and had a Physician's Orders for anti-convulsant (used to treat seizures) medications, the Facility failed to ensure the resident was free from significant medication errors when he/she was not administered the medication as prescribed, placing him/her at risk for seizures.

Inspectors wroteBased on records reviewed and interviews for one of three sampled residents (Resident #3), who had a history of Hypokalemia (low potassium levels in the blood) and had a Physician's Order for potassium supplements, the Facility failed to ensure nursing notified the Provider when he/she did not receive the supplement as ordered.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #3), who had a history of Hypokalemia (low potassium levels in the blood) and a Physician's order for Potassium Sodium Sulfate (a supplement that can help maintain a therapeutic potassium level in the body), the facility failed to ensure they obtained and Resident #3 was provided the medication, as ordered by his/her Provider.

Inspectors wroteBased on observation, interview and policy review, the facility failed to properly follow sanitation and food handling practices to prevent the risk of foodborne illness in accordance with professional standards for food service safety. Specifically, the facility failed to: 1. Ensure resident food was prepared and distributed to prevent potential for cross contamination. 2. Ensure beard nets were worn in the food preparation area.

Inspectors wroteBased on observation, interview, record and policy review, the facility failed to notify the Physician of a need to alter treatment for two Residents (#130 and #73), out of a total sample of 29 residents. Specifically: 1) For Resident #130, the facility failed to notify the Physician/ Provider timely for an emergency order and/or alternative pain medication when the ordered pain medication was unavailable from the pharmacy to address the Resident's pain. 2) For Resident #73, the facility failed to notify the Provider when the ordered pain medication regimen was determined to be ineffective in managing the Resident's pain.

Inspectors wroteBased on observation, interview, record and policy review, the facility failed to provide care in accordance with professional standards of practice for two Residents (#66 and #71), out of a total sample of 29 residents. Specifically, 1. For Resident #66, the facility failed to: a)complete PICC device dressing changes as ordered by the Physician, b)complete external catheter length measurements as ordered, c)notify the Provider timely when changes in external catheter length and arm circumference measurements were identified for a Resident with a Peripherally Inserted Central Catheter (PICC: a thin, soft tube that is inserted into a vein in the arm, for long-term antibiotics, nutrition, medications, and blood draws. [...]

Inspectors wroteBased on observation, interview, record and policy review, the facility failed to provide pain management consistent with professional standards of practice for two Residents (#130 and #72), of two applicable Residents reviewed for pain, out of a total sample of 29 residents. Specifically: 1) For Resident #130, the facility failed to provide pain medication as ordered for severe pain reported by the Resident. The facility also failed to contact the Physician/ Provider for an emergency order and/or alternative pain medication to aid in managing the Resident's pain when the ordered pain medication was unavailable from the pharmacy to be administered. 2) For Resident #73, the facility failed to appropriately monitor the Resident for effectiveness of prescribed pain medication, and notify the Physician/ Provider for evaluation and modification of the pain medication regimen as needed.

Inspectors wroteBased on interview and record review, the facility failed to ensure that one Resident (#24) out of a total sample of 29 residents, was afforded the ability to review/sign documents pertaining to his/her medical care. Specifically, the facility failed to ensure that Resident #24, who was identified as his/her own person and was able to make his/her own decisions, was able to review and sign documentation relative to Advanced Directives (life sustaining measures that can be taken when a person's heart stops or they fail to breathe on their own) and ancillary services that could be provided while at the facility.

Inspectors wroteBased on record review, policy review, and interview, the facility failed to accurately complete a Level I Preadmission Screening and Resident Review (PASARR- screen to determine if a resident had an intellectual or developmental disability (ID or DD) and/or serious mental illness (SMI) and needed further evaluation) for one Resident (#112), out of a total sample of 29 total residents. Specifically, for Resident #112 the facility failed to accurately complete a Level I PASRR indicating that the Resident had a diagnosis of Bipolar Disorder, and received Behavioral Health Services within the last two years in the community, resulting in a Level II PASRR Evaluation (an evaluation conducted to determine if an individual who screened positive for an SMI or ID/DD requires specialized services) not being completed as required.

Inspectors wroteBased on interview, record and policy review, the facility failed to ensure that the Resident and/or Resident Representative was provided the right to participate in the care plan process for two Residents (#2 and #122), out of a total sample of 29 residents. Specifically, the facility failed to: 1) For Resident #2, ensure that quarterly care plan meetings were conducted as required. 2) For Resident #122, ensure that an admission and subsequent care plan meetings were conducted as required.

Inspectors wroteBased on observation, interview, record and policy review, the facility failed to ensure that an audiology (hearing services) appointment was arranged for one Resident (#10), out of a total sample of 29 residents. Specifically, the facility staff failed to ensure that Resident #10 was provided with audiology services as required, when the Resident voiced a concern about being able to hear adequately.

Inspectors wroteBased on interview and record review, the facility failed to ensure that one Resident (#106) out of a total sample of 29 residents received trauma-informed care in accordance with professional standards of practice. Specifically, for Resident #106 who had a history of Post Traumatic Stress Disorder (PTSD: a mental and behavioral disorder that developed from having experienced a traumatic event, causing flashbacks, nightmares and severe anxiety), the facility failed to complete an assessment and develop a care plan that included the Resident's identified PTSD triggers (certain stimuli that bring back strong memories from a traumatic event, these can include but are not limited to sounds, smells, physical actions, and thoughts, that can cause an adverse reaction).

Inspectors wroteBased on interview, record and policy review, the facility failed to ensure the Consultant Pharmacist recommendations were responded to timely for two Residents (#71 and #58), of five applicable residents reviewed, out of a total sample of 29 residents. Specifically, the facility failed to: 1. For Resident #71, implement two Consultant Pharmacist recommendations directed to Nursing staff when the Resident was prescribed an antipsychotic medication (used to manage psychosis or severe mental condition when thought and emotions are affected and some contact with reality is lost). 2. For Resident #58, implement the Consultant Pharmacist recommendation to clarify the administration orders of a prescribed inhaler.

Inspectors wroteBased on interview and record review, the facility failed to ensure that one Resident (#73) out of a total sample of 29 residents was free of significant medication errors. Specifically, for Resident #73, the facility failed to ensure two nurses (Nurse #10 and Nurse #9) administered the correct opioid pain medication (a drug class of strong pain medications) as ordered by the Physician on two separate occasions, placing the Resident at risk for sedation (medication induced calm and/or sleepiness) and respiratory depression (slowing of breathing that can include stopping breathing all together).

Inspectors wroteBased on observation and interview, the facility failed to ensure that medications were stored in a sanitary manner on two units (Kensington and [NAME]) out of five units observed. Specifically, the facility failed to ensure that the medication refrigerators on the Kensington Unit and the [NAME] Unit were maintained in a clean and sanitary manner.

Inspectors wroteBased on interview and record review, the facility failed to ensure Physician Ordered lab work and diagnostic testing was obtained for one Resident (#2), of five applicable residents reviewed for unnecessary medication review, out of a total sample of 29 residents. Specifically, the facility failed to obtain yearly lab work and diagnostic testing for Resident #2 who was prescribed an antipsychotic medication (used to treat mental disorders) and had a history of breast cancer.

Inspectors wroteBased on record review and interview, the facility failed to maintain complete and accurate medical records for one Resident (#30) out of a total sample 29 total residents. Specifically, for Resident #30, the facility failed to maintain accurate and consistent medical records relative to Advanced Directives (written instructions that are provided for medical care and the individual's health care wishes i.e: MOLST [Massachusetts Medical Orders for Life Sustaining Treatments]).

Inspectors wroteBased on records reviewed, observations, and interviews, for one of three sampled residents (Resident #1), who sustained two unwitnessed falls, and was later diagnosed with a C1 cervical fracture which required a cervical collar to be worn at all times, the Facility failed to ensure they maintained a complete and accurate medical record when nursing failed to 1) document scheduled neurological checks following both unwitnessed falls and 2) failed to transcribe the order to wear a cervical collar at all times to prevent a high spinal cord injury, upon discharge from the hospital.

Inspectors wroteBased on interviews and records reviewed, for 4 of 9 sampled residents (Residents #1, #2, #3 and #4) who resided on a unit that the Facility intended to close for renovations on an undetermined future date, the Facility failed to ensure that prior to discharging Resident #1, #2, #3 and #4 from the Facility, that they were made aware of their right to 30 days notice of intent to discharge, that they had the right to appeal the discharge and should have been permitted to remain in the Facility until the appeal hearing was held.

Inspectors wroteBased on interviews and records reviewed for 4 of 9 sampled residents (Residents #1, 2, #3 and #4) the Facility failed to ensure they provided appropriate advanced written Notice of Transfer and Discharge to the Resident and/or Resident's Representative at the time the Facility initiated discharges for Residents #1, #2, #3 and #4, in accordance with the Facility Policy. Findings Include: Review of the Facility Policy titled Transfer or Discharge, Facility-Initiated, dated October 2022, indicated that each resident will be permitted to remain in the Facility and not be transferred or discharged unless: [...]

Inspectors wroteBased on interview, policy review, and record review, the facility and its staff failed to ensure quality care and services were provided to one Resident (#161) out of a total sample of 37 Residents. Specifically, the facility failed to: A) monitor and notify the Physician of critical lab values consistent with hypernatremia and acute kidney injury resulting in a hospitalization, and B) identify, address and monitor an unplanned, significant weight loss by failing to re-check weights timely, monitor enteral (a liquid form of nutrition delivered into the digestive system) intake consistently, and implement nutritional interventions to prevent further significant weight loss.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure its staff prevented one Resident (#58), of 10 applicable residents, from developing two pressure injuries/ulcers (injuries to skin and underlying tissue resulting from prolonged pressure on the skin), out of a total sample of 37 residents. Specifically, the facility staff failed to: a) accurately assess the Resident's risk for developing pressure injuries while at the facility for post-operative care after spinal surgery, and b) also accurately assess, document and treat the Resident's pressure injuries.

Inspectors wroteBased on observation, interviews, record and policy review, the facility failed to ensure that staff identified, addressed and monitored significant weight loss of one resident (#82) with unplanned, significant weight loss, out of a sample of 37 residents. Specifically, the facility failed to notify a Physician or Nurse Practitioner of Resident #82's change in condition, recheck weights timely, weigh resident at the frequency ordered by the Physician and implement nutritional interventions to prevent further significant weight loss.

Inspectors wroteBased on observation, record review, and interview, the facility and its staff failed to provide: 1) sufficient nursing staff (including Certified Nurse Assistants [CNAs]) for its Residents, and 2) staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the facility assessment, for five out of five units observed.

Inspectors wroteBased on record review and interview, the facility failed to ensure its staff conducted regular inspections of all bed frames, mattresses, and bed rails, as part of a regular maintenance program to identify areas of possible entrapment on five out of five units.

Inspectors wroteBased on record review and interview, the facility failed to ensure its staff: 1) provided a written Notice of Transfer and Discharge to the Resident and/or Residents Representative at the time of discharge for seven Residents (#17, #79, #160, #77, #133, #143, and #126), and 2) notified a Representative in the Office of the State Long Term Care Ombudsman when a resident was transferred from the facility for four Residents (#79, #160, #36, and #126), out of a total sample of 37 residents. Findings Include: Review of the facility policy titled Transfer or Discharge, Facility-Initiated, dated October 2022, indicated the following: -Notice of Transfer is provided to the resident and representative as soon as practicable before the transfer and to the Long-Term care Ombudsman when practicable . 1. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure its staff provided written notification of the Bed- Hold Policy to the Resident and/or the Resident's Representative for seven Residents (#17, #79, #160, #77, #133, #143, and #126) out of a total sample of 37 residents, who were transferred to the hospital. Findings Include: Review of the facility policy titled Bed-Holds and Return, dated October 2022, indicated the following: -All residents/representatives are provided written information regarding the facility and state Bed-Hold Policies .at the time of transfer (or, if the transfer was an emergency, within 24 hours). 1. For Resident #17, a written copy of the Bed-Hold Policy at the time of discharge or shortly thereafter was not provided to the Resident and/or the Resident Representative. Resident #17 was admitted to the facility in May 2022. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure its staff implemented the plan of care for five Resident's (#160, #95, #134, #133 and #143) out of a sample of 37 total residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure its staff provided urinary catheter (a flexible tube inserted into the body to allow urine to flow) care and services relative to: 1) proper positioning of a urinary draining bag to prevent the backflow of urine into the bladder, 2) proper infection control practices for catheter care specifically ensuring catheter bags were kept off the floor to prevent infection, and 3) documented post void residuals (the amount of urine retained in the bladder after a voluntary void) and straight catheter output (the amount of urine that is voided) amounts as ordered by the Physician, for four Residents (#62, #134, #159 and #36), of six applicable residents with urinary catheters, out of a total sample of 37 residents. Findings Include: [...]

Inspectors wroteBased on interview and in-service documentation review, the facility failed to ensure that the nursing staff received the appropriate competencies and skill sets necessary for the care and treatment of residents. Specifically, the facility failed to: 1) Ensure annual competencies were completed and documented for two out of two certified nursing assistants (CNAs), and five out of five licensed nurses whose education records were reviewed.

Inspectors wroteBased on observation, interview, and policy review, the facility failed to ensure that its staff secured the emergency medication kits (E-kits), and that all medications were accounted for, in four out of five medication storage rooms reviewed.

Inspectors wroteBased on record review and staff interview, the facility and its staff failed to ensure the drug regimen for residents was free of unnecessary psychotropic medications for four Residents (#103 and #92, #141 and #95), out of a total sample of 37 residents. Specifically, the facility failed to: 1) ensure PRN (as needed) orders for the psychotropic medications were limited to 14 days, and a renewal rationale documented for Resident #103, 2) ensure AIMS (Abnormal Involuntary Movement Scale) testing was completed and side effects were monitored for the daily use of an antipsychotic medication for Resident #92, and 3) ensure PRN orders for the psychotropic medications including Trazodone were limited to 14 days, and were not renewed without prescriber rationale for the appropriateness of that medication for an extended duration for Residents #141 and #95. [...]

Inspectors wroteBased on observations and interviews, the facility failed to ensure that its staff provided meals that were palatable, and of appropriate temperatures on four out of four units observed, and ensure policies/procedures were in place for the safe reheating of food and beverage items in three out of the five unit kitchenettes observed.

Inspectors wroteBased on observations and interviews, the facility and its staff failed to ensure a homelike environment was provided for two Residents (#1 and #36), out of a sample of 37 residents. Specifically, lack of functional window shade and privacy curtains.

Inspectors wroteBased on interview and record review, the facility failed to ensure that its staff initiated a baseline care plan within 48 hours of admission for two Residents (#77 and #143), out of a sample of 37 residents. Specifically, the facility staff failed to initiate baseline care plans relative to falls for both residents with previous history of falls.

Inspectors wroteBased on interview and record review, the facility failed to ensure its staff developed a discharge plan for one Resident (#17) out of a sample of 37 residents. Findings Include: Review of the facilities job description for a Social Worker indicated the following: -Coordinates discharge planning and assists with developing an organized discharge plan for all residents. Resident #17 was admitted to the facility in May 2022. Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #17 scored a 13 out of 15 on the Brief Interview of Mental Status (BIMS) assessment indicating that he/she was cognitively intact. During an interview on 1/31/23 at 9:52 A.M., Resident #17 said his/her plan was to transfer to another skilled nursing facility but that he/she had not heard any more from the Social Worker regarding the transfer. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure its staff provided foot care for one Resident (#36), out of a total sample of 37 residents. Specifically, the facility staff failed to ensure diabetic foot care was provided to maintain good foot health per facility policy and professional standards.

Inspectors wroteBased on observation, interview, and policy review, the facility failed to ensure its staff maintained an environment that remained free of accident and hazards. Specifically, the facility staff failed to: 1) safely maintain unlocked and unattended medication and treatment carts, and 2) appropriately monitor and secure medications, on two (Kensington and [NAME]) of five units.

Inspectors wroteBased on observation, interview, and policy review, the facility failed to ensure its staff stored drugs and biologicals in accordance with their policy and manufacturer recommendations on two out of five units. Specifically, the facility: 1) failed to remove expired medication from the medication cart, 2) failed to properly label medication when opened, and 3) failed to ensure an unopened insulin kit was refrigerated. Review of the policy titled, Storage of Medications, dated [DATE], indicated the following: -Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls. -Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure its staff provided documented evidence of the ongoing assessment of an Arteriovenous Fistula (AV- connection between artery and vein that is used to provide dialysis) site for one Resident (#17) receiving dialysis (a procedure where a machine filters waste and toxins from the blood when the kidneys are no longer functioning properly), out of a total of 37 sampled residents. Findings Include: Review of the facility policy titled Hemodialysis Pre and Post Care, revised 3/2010, indicated the following: -Routes of hemodialysis treatments will be monitored for potential complications or infections . -Treatment sites are to be assessed regularly . -Access sites should be inspected for signs and symptoms of inflammation or infections process; bruit and thrills . [...]